Reconstructive Surgery

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Reconstructive surgery involves the restoration of a wound or defect that was created by ablative surgery. The three main goals of reconstructive surgery are as follows:

Protect vital structures: This involves separating non-sterile areas, such as the mouth, throat and nose, from sterile areas, such as the neck and brain. Covering important structures with healthy tissue protects them from potential life-threatening damage—the most important job of a reconstructive surgeon.

Restore function: Sometimes removing tumors will affect how your body works, including what you feel, how you move, how you breathe, how you eat and how you chew and swallow. A good reconstructive surgeon will try to restore function as much as possible. Obtaining the best function post-operatively will require rehabilitative work on your part in coordination with a physical therapist, occupational therapist and speech and swallowing therapist.

Restoring form: This means making your appearance as close to normal as possible so you are not afraid to go out in public and return to active family life and gainful employment.

Reconstructive surgery can be done by the same surgeon who does the ablation. In some cases, a separate reconstructive surgery specialist may perform that part of the surgery. The reconstructive specialist is particularly important following large and complex ablations. Having a separate reconstructive surgeon can sometimes allow the surgery to go quicker because for some reconstructions, both surgeons can work at once. This is especially true for reconstructions in which tissue from another part of the body is used for reconstruction.

The reconstructive surgery can be done during the same surgery as the ablation; however, in some cases it might be better to wake you after the ablation and perform the reconstruction on a later date. If your surgeon is confident that the entire tumor was removed (often with the help of frozen section microscopic analysis of the edges of the specimen), he or she might proceed with immediate major reconstruction. However, frozen section is really just a snapshot of a few sections of the specimen; therefore, in some cases your surgeon might decide to delay the reconstruction by a week or so for the pathologist to study the tumor and the margins. This is a better way to find out details of the tumor and to see if it has been completely removed with a rim of normal tissue. Returning later to complete the reconstruction is called a delayed or staged reconstruction.

When considering which reconstruction is best for you, your surgeon will consider a number of options. In general, the simplest reconstruction that achieves the three main goals described above is the best reconstruction.

You can read about different reconstructive options in the following section.

Wound Closure

Facial reanimation surgery

Prosthetic rehabilitation

Skin grafts

Primary nerve grafting

Dental rehabilitation

Primary closure and local flaps

Temporalis muscle Transposition

Auricular

Healing by secondary intention

Static sling

Orbital

Regional flap surgery

Free muscle transfer with cross facial nerve graft

Nasal

Free flap surgery

Surgery for recurrence

Despite all the medical advances made in surgery, radiation, chemotherapy and biologic medications, sometimes tumors return after treatment. This is called recurrent cancer. Recurrent cancer is different from persistent cancer.

Persistent cancer: This is cancer that has never gone away completely, despite finishing treatment. The cancer has persisted through treatment.

Recurrent cancer: This is cancer that has come back after a period in which the cancer appeared to have been completely gone after treatment. The cancer has recurred after being treated. Recurrent cancer is different from a new primary cancer and a synchronous cancer. A new primary cancer is either a cancer that shows up more than 10 years after treatment or after any time, but in a different location from the original tumor. A synchronous primary cancer is a second focus of cancer, different from the first tumor and found at the same time as another cancer.

Recurrence of cancer is classified in three different ways:

Local recurrence: Local recurrence is when cancer in the same site as the original primary tumor has returned after being apparently successfully treated and removed.

Regional recurrence: Regional recurrence is when a tumor has been effectively treated but returns later in the lymph nodes. Your doctor will do a thorough examination to make sure the cancer in the lymph node is not from a different site in the head and neck (which would be called a new primary cancer).

Distant recurrence: Distant recurrence is when cancer has been effectively treated but later shows up in a distant site, such as the lungs, bone, liver or brain. Your doctor will work to ensure the cancer is not from a different site or a primary tumor in that organ. This can be done by taking a biopsy, looking at the cells under the microscope and comparing them to cells from the original tumor.

In both recurrent cancer and persistent cancer, your head and neck cancer doctors will need to meet and discuss different treatment options. In many cases, recurrent or persistent cancer is treated with surgical removal. A cancer that returns or is not removed with standard treatments likely means the cancer is aggressive.

Surgery for recurrent or persistent cancer is called salvage surgery. Salvage surgery is usually more extensive and more difficult than surgery to remove a cancer that has not been treated at an earlier time. This surgery is more difficult for the following two reasons:

The cancer has proven to be aggressive, and therefore an aggressive surgery to remove the tumor is often your best chance at being cured.

Scarring and inflammation after previous treatment can make salvage surgery more difficult than primary surgery.

In addition, salvage surgery frequently requires a more difficult reconstruction than primary surgery. This is especially true if there is any chance for radiation and/or chemotherapy as additional treatment following the salvage surgery.

The risks of complications are higher in salvage surgery than in primary surgery. For example, breakdown of incisions and leaks of saliva are more common in patients who have been previously treated with chemotherapy and radiation than those previously treated with radiation alone. The risks of complications is higher in patients previously treated with radiation alone that those who have never received chemotherapy or radiation.

Salvage surgery is often the best option to treat recurrent or persistent cancer. However, salvage surgery and the subsequent required reconstruction can be very difficult and are often your last chance at curing the cancer. Therefore, it is extremely important that salvage surgery be performed by an experienced team of surgeons.

Exposure for surgery

In order to remove the tumor, your surgeon needs to get to the tumor or expose the tumor. The route your surgeon takes to remove the tumor is called surgical access. The following are examples of surgical access:

If your tumor is toward the back part of the tongue, your surgeon might make an incision in the middle of your lip to cut the jawbone and to be able to see and remove the tumor with a rim of normal tissue around it—called a lip-split with a mandibulotomy.

If you have a tumor on the hard palate growing into the maxilla bone, your surgeon might make an incision along the sidewall of the nose and split the upper lip to expose the maxilla bone and completely remove the tumor—called a Weber-Ferguson incision for surgical access.

If your tumor is in the parotid gland in your cheek, your surgeon will make an incision in front of your ear down to your neck along a natural skin crease and then tunnel under the skin to reach the tumor in your cheek. This will help your surgeon identify and preserve the nerve that controls the muscles of the face and will allow him or her to hide the incisions as best as possible.

Your care team could provide many more examples, but your surgeon should tell you about his or her plan for exposure or surgical access to perform an adequate ablative surgery and reconstructive surgery. Be aware: The required exposure might change, depending on the findings during the surgery. You should be told of various options before you are sedated with general anesthesia. Ask what access your surgeon plans to take to remove your tumor.